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The Impact of Enhanced Recovery and Fast Track Surgery on Postoperative Analgesia and Opioid Use: A Systematic Review
Session: EX-02
Thurs, April 19, 6-6:10 pm
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The Impact of Enhanced Recovery and Fast Track Surgery on Postoperative Analgesia and Opioid Use: A Systematic Review

Cathy He, MD; Sylvia Li, MD; Alexander Stone, MD; Jean-Pierre Ouanes, DO; Christopher L. Wu, MD; Michael C. Grant, MD

The Johns Hopkins University; Departments of Anesthesiology and Surgery; Baltimore, Maryland

Background

•Enhanced Recovery After Surgery (ERAS), which evolved from Fast Track Surgery (FTS), is a transdisciplinary program designed to implement bundled evidence-based process measures to improve the quality of perioperative care.
•A cornerstone of these programs includes the application of multimodal analgesia to limit the reliance upon opioid-based medications. 
•Through this mechanism, ERAS programs may be leveraged to address the ongoing national opioid crisis.
•We have performed a systematic review to evaluate the impact of FTS and ERAS programs on pain-related endpoints including overall postoperative opioid requirements. 
 
Methods
 
•This study utilized the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. 
•PUBMED, EMBASE, CINAHL, Web of Science and COCHRANE databases were queried from inception onward for randomized controlled trials (RCTs) involving adult patients undergoing general anesthesia with FTS/ERAS protocols compared to standard or conventional surgical care.
•The predefined primary outcomes include inpatient postoperative opioid administration and patient-reported pain scores.
•After evaluation of 5,465 initial studies, results from 26 independent RCTs (n=2,318) were ultimately included in the systematic review. 
•Individual studies were reviewed to identify specific multimodal medications and regional analgesia techniques employed. 

Results

•There was significant inter-study variability with respect to the reporting of opioids and/or pain scores. 
•Although a total of 11 of 26 studies reported postoperative opioid requirements, there were significant discrepancies with regards to the frequency of outcome assessments, ranging from several hours to as many as 30 days.
•18 studies evaluated patient pain scores, however, a variety of scoring modalities were utilized, making direct comparisons difficult.
•Process measures associated with improved analgesia control included epidurals, scheduled NSAIDs, and scheduled Acetaminophens.
•Only four studies reported on both analgesic outcomes. 
•Qualitatively, FTS/ERAS was associated with a reduction in postoperative opioid requirements compared to controls. 
•Patients who received FTS/ERAS care generally reported lower pain scores (visual analogue scale [VAS] or pain numeric rating score [NRS]), be it with movement or at rest, compared to controls.
 
Discussion
 
•This review suggests that among trials designed to assess pain-related endpoints, a formal FTS/ERAS program can reduce postoperative opioid requirements and provide improved postoperative analgesia. 
•Conclusions are limited by the significant degree of variability in reporting of analgesic outcomes and inconsistency with regard to the specific analgesic process measures employed by each study. 
•Further high quality prospective studies concentrating on pain-related outcomes are necessary to comprehensively evaluate the potential for ERAS programs to be utilized to limit acute postoperative opioid administration and conversion to chronic opioid use.
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